Provider Demographics
NPI:1083702146
Name:CHERYL R BROWN, PC
Entity Type:Organization
Organization Name:CHERYL R BROWN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:B
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-356-5060
Mailing Address - Street 1:1520 CARLEMONT DR STE M
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-1836
Mailing Address - Country:US
Mailing Address - Phone:815-356-5060
Mailing Address - Fax:815-356-7898
Practice Address - Street 1:1520 CARLEMONT DR STE M
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1836
Practice Address - Country:US
Practice Address - Phone:815-356-5060
Practice Address - Fax:815-356-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16-004864213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1625610OtherBCBS
IL214265Medicare PIN